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CotrlRlerCe.Wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 ✓ <br /> iseo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Dspartmertt of Commerce SS 1 �- 3.5 <br /> Sanitary Permit Application StateTr cu/onNomber (� <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental .p - <br /> unit is required prior to obtaining a sanitary permit Note: Application fomes for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,a.15. 1 m),Stats. <br /> L ApifficadanInformation-PleasePrintADInformation S( 04 43ot ela T✓&i <br /> Property Owner's Name Parcel#07-032-2-41-1!4'5 e cv'- oiq� <br /> Kav;n tea✓�rlteacu JJ�D� � 3d- 9/00 - atioo <br /> Property Owner's Mailing Address Property I-ovation <br /> ,79 � dd <br /> � (�,Ell6eee lfve Gest Lot <br /> City,Stam Zip Cale Phone Number Y., Y., Section y <br /> Wh j' +c l�!a� cuele ane) <br /> IL Type of Building(check all dint .T.r//D Lot# T V/ N; R�E or <br /> LY1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Bloekn Pint Ad j&f Fo 8(jell 4copc5 <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑Stam Owned-Describe Use CSM Number ❑Village of <br /> CK..of .,.5Wlis <br /> III.Type of Permit: (Check only one box on tine A. Complete tine B if appdnhle) <br /> A. 0 New System ❑Replacement System ❑Treatmeat/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer m New Liat Previous Permit Number and Dam Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> A Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Gude ❑Moond>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tack ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Wormation: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Diapered Ares Required(at) Dispersal Area Proposed(at) System Elevation <br /> Ver.Tank Wo Capacity in Total M of Manufacturer o <br /> Gallons Gallons Unita g5 tQ� u <br /> New Tanks Exining Tanks £ y y <br /> Septic or Holding Tads <br /> Doang Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plana <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number BusinessArora Number <br /> ?,GiIC J`/o k, n .! �Ge.ie»-►c 1107 .:. aa3`>pJ"/ 7/J=1G'L- �/.r7 <br /> Plumber's Address(Street,City,Stam,zip Code) _ <br /> 7 7i a /Pon y .7..i;-- G✓.Z- S-/ fv_,;p <br /> VIIL Conan"/De Use Only <br /> Approved ❑Disapproved Permit Fee Dam Issued Issuing rare <br /> ❑Owner Given Reason for Denial J �/w U +r�/�1 <br /> IX.Conditions of Approval/Reasons;for Disapproval <br /> Attach to waspleta plaoslor the syamm and srbah loth Caamya ly an paper said tea than a fa x 11 huhs Is size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />